British Journal of Addiction (1986) 81, 757-763

Opioid Users' Attitudes Towards and Useof NHS Clinics, General Practitioners andPrivate Doctors

TREVOR BENNETT' & RICHARD WRIGHT^

'Senior Research Associate, University of Cambridge, Institute of Criminology, 7 West Road,Cambridge CB3 9DT, U.K. and ^Assistant Professor, University of Missouri—St Louis,Department of Administration of Justice and Center for Metropolitan Studies, 8001 NationalBridge Road, St Louis, Missouri, U.S.A.

SummaryThe paper reports some of the findings of a study which investigated opioid users'views on and use of availabletreatment services in Britain. Samples were drawn from among addicts currently receiving a prescription froma National Health Service (NHS) clinic, a general practitioner and a private practitioner and addicts whowere currently dependent solely on black-market supplies. Addicts were interviewed using a combinedstructured and semi-structured interview schedule. There was little evidence that users dependent on black-market sources only had actively rejected available treatment services in the past. The majority of the black-market users had approached at least one type of doctor in connection with their addiction. Most of the userscurrently receiving a prescription from a clinic or a general or private practitioner had at some timeapproached other types of doctor. The main reasons given for not approaching various types of doctorconcerned a belief that such doctors were unavailable locally and an expectation that they were unwilling toprescribe opioids. Given a free choice, the majority of addicts said that they would prefer to attend a GP ratherthan a clinic or private practitioner.

IntroductionThe present system for the treatment of opioidaddiction derives in part from the recommendationsof expert committees'-^ and in part from localinitiatives by health authorities and individualdoctors. Consequently, its development has notbeen uniform and medical services vary across thecountry. One feature of this development is theinvolvement of three different types of doctor in thetreatment of addiction: hospital-based doctors at-tached to drug treatment centres, general practition-ers and private doctors. A central issue in thecurrent debate about the nature and structure ofservices to be made available for tackling drug

misuse is the role to be played by each of these threetypes of doctor.

In 1982, the Advisory Council on the Misuse ofDrugs (ACMD) recognized in their report' the needfor a co-ordinated and comprehensive system andrecommended the development of multi-discipli-nary regional drug problem teams based, wherepossible, at the hospital-based drug treatmentcentres. The report recognized a role for generalpractitioners, although expressed some concernabout their involvement and proposed a number ofsafeguards. They expressed much greater concernabout the treatment of addiction by private practi-tioners and held the view that charging fees created

757

758 Trevor Bennett & Richard Wright

moral and ethical problems which could not easilybe resolved.

More recently, the Report of the Medical Work-ing group on Drug Dependence* drew attention tothe responsibility of general practitioners to providefor both the general health needs of drug misusersand their drug-related problems. The report ex-pressed a concern that some doctors were unwillingor reluctant to see drug misusers. Other commenta-tors have drawn attention to the growing number ofusers presenting themselves to general practitionersand have speculated that the number is likely toincrease.'

The debate about the role of various types ofdoctor has included very little on the views of theaddicts themselves. Any system which aims to treatopioid addiction must first attract drug users. Oneof the principle functions of the National HealthService (NHS) clinics when they were first estab-lished in 1968 was to attract opioid users intotreatment. Edwards,' for example, notes: "One ofthe original assumptions of treatment policy wasthat, by setting up clinics which offered opiates onprescription, addicts would be drawn into contactwith a helping system" (p. 8).

Until the attitudes and behaviour of users arebetter documented, it is unknown what proportionwill be drawn into the system and what proportionwill reject it. Some commentators have recentlyargued that the clinics are no longer attractive toaddicts. Ghodse' claims that many users are optingout of the clinic system and Dally* believes thatmany are actively rejecting the drug treatmentcentres.

Reasons cited for the supposed dissatisfactionwith the clinic system include the policy of manyclinics to prescribe opioids in oral form and toreduce or eliminate the use of injectable drugs,'-' thereduction in dosage of prescribed drugs generallyand the preference for rapidly reducing rather thanmaintenance treatment regimes,'" the widespreaduse of group therapy, and the strict rules ofbehaviour that patients must adhere to in order to beaccepted for, or to continue in, treatment."

Most of the evidence available about the views ofopioid users on various treatment methods derivesnot from systematic empirical research, but fromimpressions gained by doctors and other staff whowork directly with addicts. With a few notableexceptions,'^ very little research has been conductedon the views of addicts. It has been argued that, inthe absence of empirical research data, clinic policyhas evolved from no more than a set of unfounded

beliefs held by doctors about how drugs should beprescribed to outpatient addicts.'"

The organization RELEASE, in response to theAdvisory Council report Treatment and Rehabilita-tion,'^ complained that the proposals were entirelyinappropriate to the needs of drug users and pointedout that the Council had made its recommendationswithout any representation from the addicts them-selves. Trebach''' believes that it is imperative todesign a system which will attract a large proportionof addicts into treatment: "It is considered sinful, ofcourse, for policy-makers to take into account thetastes of drug users, but those tastes must berecognized as among the most important elements inthe rational design of future policies" (p. 272),

Unless the needs of addicts are fully understoodand their preferences known any proposal for afuture system for dealing with addiction can bebased on no more than speculation and hunch.

The Present StudyOpioid users' choice of source of supply of drugsand their attitudes towards these sources was themain topic of this investigation. In order to tap aswide a range of opinion as possible it was decided toselect samples of addicts currently using differentsources of supply. In all, six samples were selected:two groups attending NHS clinics (Cambridge andBristol); two groups using black-market suppliesonly (Cambridge and Bristol); one group currentlyreceiving a prescription from one of a number ofGPs (Bristol) and one group currently receiving aprescription for opioids from one of a number ofprivate practitioners (London). All users selectedfor the research were self-admitted addicts and werecurrently using opioids. One condition for inclusionin the samples was that they consumed at least onedosage of an opioid for at least 4 days a week overthe last month. Details of the way in which thesamples were selected can be found in an earlierarticle."

A total of 135 addicts were selected and samplesizes varied from 11 in the GP group to 40 in theprivate practitioner group. The variation in sizeresulted from variation in the number of usersavailable in the case of the clinic and GP samplesand constraints on time in the case of the black-market samples. It would have been possible tointerview a greater number of users attendingprivate practitioners, but it was decided to limitsample size in order to balance the numbers asevenly as possible between the goups. The average

opioid Users' Attitudes 759

number of years since first use of an opioid was 11.8and 10.8 for the Cambridge and Bristol clinicsamples, 9.0 and 8.3 for the Cambridge and Bristolblack-market samples, 9.5 for the GP sample and13.3 for the private practitioner sample. The sex,age and total number of addicts in each sample areshown in Table 1.

The Interview ScheduleThe main method used was a combined structuredand semi-structured interview. Semi-structuredquestioning involved extended conversations withrespondents which were tape-recorded and latertranscribed verbatim. The main purpose of thesemi-structured method was to establish a rapportwith addicts and to reduce the possibility that theywould offer glib or inconsistent accounts. Responsesthat were unconvincing or did not match earlieraccounts were questioned. The interviewees werepromised that anything that they said would betreated in confidence and would not be reportedback to their doctor or anyone else at the practice.

ResultsIt has been argued that some addicts reject the clinic

system because it does not meet their needs.Addicts' earlier approaches to the three typesof doctor are shown in Table 2. The tableshows no evidence that any of the groups of addictshave in the past rejected specific licit sources ofsupply or in any sense specialized in one type ofsource.

The majority of each group said that they hadapproached at least one type of doctor in addition totheir current one. Over half of addicts in all groupshad approached a GP for opioids at some time in thepast. There is little indication from the table that theaddicts had avoided NHS clinics. Over 80% of theBristol GP and private practitioner samples saidthat they had approached a clinic and nearly three-quarters of the Bristol black-market reported doingso. Only one-quarter of the Cambridge black-market addicts, however, had approached a clinic.Their reasons for not approaching NHS clinics arediscussed later.

There was also little evidence that the black-market users had refrained from approaching licitsources of supply. Although only a minority ofCambridge black-market addicts had presented to aclinic the majority of the Bristol black-market grouphad done so and the majority of both groups hadapproached a general practitioner in connection

Table 1. Samples by Source of Supply, Mean Age and Sex

CC BC CBM BBM BGP PP* Total

Malef:

Female:

Total

age

age

30.0(27)29.6(9)

29.9(36)

31.3(7)

25.2(5)

28.8(12)

28.4(10)23.4(5)

26.7(15)

28.7(17)25.2(4)

28.0(21)

29.4(8)

21.5(3)

27.2(11)

31.5(30)31.5(10)

31.5(40)

30.1(99)27.5(36)

29.4(135)

*CC = Cambridge clinic; BC=Bristol clinic; CBM = Cambridge black-mar-ket; BBM=Bristol black-market; BCP = Bristol GP; PP=private practitioner.

fFigures in brackets refer to the total number in each category.

Table 2. Samples by Earlier Approaches to Clinics, GPs and Private Practitioners

Earlier approaches to: CC BC CBM BBM BGP PP*

ClinictGPPPNone

Total n

(12)21

57

(2)830

4924

151523

9(11)

40

3326

(20)3

36 12 15 21 11 40

* Abbreviations as Table 1.fThe figures in brackets refer to approaches other than to current source.

760 Trevor Bennett & Richard Wright

with their addiction. Relatively few addicts, how-ever, reported approaching private practitioners.

In order to determine why addicts approachedcertain kinds of doctor those receiving a prescrip-tion were asked to give their reasons for approachingtheir current doctor. Their responses are shown inTable 3.

Table 3. Samples by Reasons for Approaching CurrentDoctor

Reasons CC BC BGP PP*

Script!TreatmentOther

Total n

2934

36

570

12

821

11

20173

40

* Abbreviations as Table 1.tScript=Any reference to the drugs prescribed. Treat-

ment = Any reference to assistance in addition to receivinga prescription.

Over 80% of the Cambridge clinic group and over70% of the Bristol GP sample said that theyapproached their current doctor in order to obtain aprescription. The majority of the Bristol clinicgroup, however, and almost half of the privatepractitioner sample said that their main reason forapproaching their doctor was for treatment. Why arethere these differences? To some extent, addicts'reasons for approaching certain types of doctormatched the prescribing regime of the practice. Thepolicy of the Cambridge clinic included long-term,non-reducing prescribing and most of the addicts inthe group said that they approached the clinic for aprescription. The policy of the Bristol clinic wasdominantly one of reduction and withdrawal andmost of the addicts said that they approached theclinic for treatment. The relationship betweenstated reasons for approaching the current doctorand the type of regime offered was also apparentamong the private practitioner sample. Addictsattending private practitioners were divided intothose with doctors who offered long-term, slowlyreducing regimes and those attending doctors oper-ating short-term, rapidly reducing regimes. Overninety per cent of addicts attending doctors of theformer kind said that their main reason for ap-proaching them was to obtain a prescription,whereas, over three-quarters of addicts attendingdoctors of the latter kind reported approaching themfor some kind of treatment (usually help inwithdrawing).

Why do addicts refrain from approaching sometypes of prescriber? Addicts who had never ap-proached a clinic, a GP or a private practitionerwere asked to give reasons why they had notapproached one. Their reasons are shown in Table4. Because most of the addicts had used at least oneother source of supply in addition to their currentsource, the numbers in the table are unavoidablysmall.

Table 4. Reasons for Not Approaching Clinics, GPs andPrivate Practitioners

Reasons

Doctor not approached(all samples):

Clinic GP PP

Script 2 2 31Regime 12 16 8Consequences 12 4 8Not thought/didn't

realize/not needed 7 19 27Don't know 1 7 5

Total nt 26 45 79

*Script=Any reference to the drugs prescribed; Regi-me = Any reference to the policy or administration of thepractice; Consequences = Any reference to the effects ofattending the practice.(Other categories are self-explanatory.)

t Category totals do not necessarily add to final totalsbecause some addicts gave more than one reason.

The most frequently mentioned reasons for notseeking help from a clinic concerned the nature ofthe regime and the perceived consequences ofadmission. The main criticism of clinic regimesrelated not to the treatment method, but to theadmission procedure and the difficulty or impossi-bility of being accepted into treatment. Forexample: "A lot of my friends have gone and they'vejust been given the cold shoulder. It puts you off."Comments relating to the consequences of admis-sion concerned the problems of being known andbeing notified to the Home Office (all such com-ments were made by addicts using black-marketsupplies only): "I've always been paranoid aboutgetting registered and getting on the Home Officebooks." Only one addict reported not approaching aclinic because of the treatment methods used andonly two addicts said that they had not approachedbecause they were unlikely to receive a prescriptionthat they found suitable.

The most frequently reported reasons for notapproaching a GP fell into the category of 'Notthought/didn't realize/not needed'. Addicts said

opioid Users'Attitudes 761

either that they were able to get by using theirexisting sources of supply or that they simply hadnot considered the prospect of approaching a GP.The second largest group of responses concernedthe administration of the regime. Most of theseaccounts concerned the difficulty of being taken on.As one of them said: "I think GPs have been sohammered by addicts trying to get stuff off themthat they don't want to know any more and I thinkto go to a GP is a pointless exercise."

Other complaints concerned the negative atti-tudes of some GPs to addicts and their lack ofinterest in addicts' problems. Few of the users saidthat they refrained from approaching a GP becausethey believed that the prescription they mightreceive would be unsuitable or inadequate in someway or that the treatment method was unsatisfac-tory.

The main reasons given for not approaching aprivate practitioner related to the prescriptiongiven. In nearly all cases, the complaint concernedthe cost involved. For example: "It's the cost, isn'tit? If you're on the dole, you can't afford to pay for ascript."

The second major group of responses werecategorized as - 'Not thought/didn't realize/notneeded'. Most of these addicts said that either theycould get by using other sources of supply or thatthey had never considered approaching a privatedoctor. Some addicts feared that one of the conse-quences of being prescribed opioids by privatedoctors operating non-reducing regimes would bethat it would prolong or exacerbate their addiction:"I don't want to get into a situation where the gear istoo easily available—that would just make my habitworse. I never want to do anything that will makeme even more addicted."

In order to discover addicts' preferences fordifferent types of doctor, they were asked whichthey would choose to attend given a free choice.They were asked to assume that they would be giventhe same prescription as they were currently receiv-

ing or, in the case of the black-market sample, thatthey would receive a prescription that would justsatisfy their needs. The results are summarized inTable 5.

The largest percentage of addicts in both clinicgroups chose a clinic doctor as their preferredprescriber. The majority of addicts attending a GPchose a GP as their first choice. In these three cases,therefore, the largest percentage of subjects chosetheir current doctor as their first choice. This is notto say that the addicts had no complaints about theircurrent doctor. They were merely asked to statewhich of the three available types of doctor theypreferred.

There was no such linkage in the case of theprivate practitioner sample. The majority of theprivate practitioner group reported that they wouldrather attend a GP. Overall, the major proportion ofaddicts in four of the six samples said that their idealprescribing doctor was a GP. Very few addicts saidthat they preferred to be treated by a privatepractitioner.

It is widely believed that one of the reasons whysome addicts refrain from approaching NHS clinicsis the general policy of not prescribing heroin. Inorder to determine the preferences of the addictstowards the type of drug prescribed, they wereasked to state what kind of drug they wouldprescribe to themselves if they were given the powerto do so. The preferred type of drug is shown inTable 6.

The most frequently chosen drug was heroin inthe case of the Bristol clinic sample and the twoblack-market samples. In the case of the Cambridgeclinic, GP and private practitioner samples, themost frequently chosen drug was methadone. Veryfew addicts preferred any of the other opioids.About one quarter of the Cambridge black-marketgroup, however, said that they would prescribe tothemselves either Diconal (dipipanone with cycliz-ine) or DF118 (dihydrocodeine).

Generally, the addicts preferred the type of drug

Table 5. Samples by Preferred Choice of Doctor

Preferred choice CC BC CBM BBM BGP PP*

ClinicGPPPD/K

Total n

161235

36

6501

12

2733

15

713

10

21

3800

11

42781

40

*Abbreviations as Table 1.

762 Trevor Bennett & Richard Wright

Table 6. Samples by Preferred Choice of Drug

Preferred choice CC BC CBM BBM BGP PP*

HeroinMorphineMethadoneOpiumOtherD/K

Total n

92

22003

36

523101

12

604041

15

1135011

21

224021

11

101

24032

40

* Abbreviations as Table 1,

Table 7. Samples by Preferred Method of Administering Opioids

Preferred choice

InjectionOralD/K

Total n

CC

3033

36

BC

561

12

CBM

915

15

BBM

1371

21

BGP

452

11

PP*

3163

40

* Abbreviations as Table 1,

that they were currently being prescribed or werecurrently using. Most of the two black-marketgroups were current users of street heroin, whereasmost of the addicts in treatment were prescribedmethadone. It is interesting that only 43 of a total of135 users said that they would prescribe heroin tothemselves given a free choice.

It is also widely believed that addicts fail toapproach NHS clinics for help with their addictionas a result of the general policy to prescribe non-injectable drugs. In order to determine addicts'views on the method of administering drugs, theywere asked to state the way in which their preferreddrug would be taken. Their responses are summar-ized in Table 7.

The majority in four of the six groups favouredinjection. The largest proportion of users in both theBristol clinic and Bristol GP groups said that theypreferred to take their drugs orally. Overall, addictspreferred the method of administration thatmatched their current method. Most of the addictsin the Bristol clinic and GP sample were prescribedmethadone in linctus form and most preferredmethadone linctus, whereas most of the Cambridgeclinic and private practitioner addicts were pre-scribed injectable drugs and most preferred injec-tion. In addition, the majority of the users depen-dent on black-market supplies took their drugs by

injection and the majority of these preferred injec-tion as the method of administration.

DiscussionThe main aim of the study was to determine addicts'use of and views on available treatment facilities inBritain. Opioid users from different parts of thecountry and using different sources of supply wereinterviewed and asked about their past and currentuse of clinic, general practice and private practicedoctors and their attitudes towards them.

There was little evidence that those dependent onblack-market sources had actively rejected licitsources of supply. Over 70% of the Cambridgeblack-market group and over 80% of the Bristolblack-market group said that they had approachedat least one type of doctor for opioids. Those whohad not approached a doctor rarely explained this asa result of either the prescription or the treatmentbeing unacceptable. Typical reasons why black-market addicts had not approached NHS clinicswere a belief that they would not get taken on and afear of being known by the Home Office. The mostfrequently stated reasons for not approaching GPswere lack of knowledge that GPs could help and thebelief that they would not be accepted. Theirreasons for not approaching a private doctor most

opioid Users'Attitudes 763

frequently concerned the costs involved and the lackof knowledge that they could help.

Most of the addicts currently receiving a pre-scription from one of the three types of doctors hadin the past approached other types of doctor. Themajority of all users in receipt of a prescription hadapproached a GP at some time. Relatively few hadapproached private doctors.

Reasons for presenting to doctors varied betweensamples. Those attending a regime that operated apolicy of long-term, slow reduction typically saidthat they approached their doctor for a prescription.Those attending a short-term, rapid reductionregime usually said that they had approached forhelp in achieving withdrawal. Few addicts spoke ofother needs such as psychiatric help or individual orgroup therapy.

Given a free choice, most said that they wouldprefer to be treated by a GP. The majority of thosewho said that they preferred to be treated by a clinicdoctor were currently attending a clinic. If given thepower to prescribe their own drugs, most addictswould choose either heroin or methadone. Gener-ally, addicts chose the drug that they were currentlyusing. Most said that they preferred to take theirdrugs by injection. Addicts currently receivingopioids in oral form were most likely to report apreference for oral preparations.

What are the implications of these findings forpolicy makers and planners? The fear that someaddicts might reject treatment facilities is probablyoverstated. It is believed, for example, that someaddicts refrain from approaching NHS clinicsbecause of the type of treatment method or becauseof the reluctance of consultants to prescribe heroinor injectables. Very few of the black-market addictscited these arguments as reasons for not approach-ing clinics. The main problem identified by theblack-market addicts was a fear of being notifiedand known to the Home Office.

It has been suggested that GPs should becomemore involved in the treatment of addiction.'' On thebasis of addicts' accounts, it seems likely that thisproposal would meet with their approval. The

majority of those interviewed said that ideally theywould prefer to be treated by a GP. The majorreasons given for not approaching GPs were thedifficulty of being taken on and the lack ofknowledge among addicts that they could treataddiction. The only serious drawback mentionedwas the negative attitudes of some GPs towardsaddicts.

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